Foster Child Medical History Form
Child Information
Full Name
Date of Birth
Gender
Male
Female
Other
Caseworker Name
Health Insurance
Insurance Provider
Policy Number
Medical Providers
Primary Physician
Physician Phone Number
Medical History
Allergies
Current Medications
Chronic Conditions
Major Surgeries or Hospitalizations
Immunization Records
Up to Date?
Yes
No
Unsure
Additional Notes
Mental and Behavioral Health
Past or Current Behavioral Concerns
Counselor/Therapist Name
Counselor/Therapist Contact
Other Information
Dietary Restrictions
Additional Comments